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ECR 2013 / C-1748
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MRI findings of breast silicone implants, including unusual signs of rupture and extravasation of the silicone gel. A pictorial essay
Congress: ECR 2013
Poster No.: C-1748
Type: Educational Exhibit
Keywords: Breast, MR, Education, Education and training
Authors: M. H. Siqueira Mendonça, S. Nagae, V. Merjane, F. Finguerman Dwek, D. S. Silva, L. Yamashita ; Sao Paulo, SP/BR
DOI:10.1594/ecr2013/C-1748

Imaging findings OR Procedure details

Imaging findings:  Signals of intra and extracapsular rupture were identified. Even without evidence of rupture, silicone migration to the regional lymphnodes, axillary, and internal thoracic chains were detected. Some implants were rotated. In 2012, patients were more concerned about their implants manufacture and integrity due to the PIP™ scandal; in this patient’s group the rupture signals were exuberant and silicone migration more likely to be detected. PIP™ and Rofil™ implants showed a hypointense discoid structure in the posterior contour, except those with extensive rupture. In one patient there was migration of the silicone gel to the lactiferous ducts that caused nipple discharge. In another, the ruptured implant was behind the major pectoral muscle and the new implant was anterior to the muscle.

 

A major problem of dissatisfaction after breast augmentation mammoplasty is the contracture of the fibrous capsule around the implant. In spite of the fact that capsular contracture is clinically detected and diagnosed, sometimes it is possible to observe imaging findings associated to the contracture. Fig. 8,9

 

Fig. 8: T2 FSE axial image. The implant form variation is noted. The globe-like shape was related to clinical findings of capsular contracture and implant rotation.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 9: Same patient as shown in Fig. 8. Axial image, STIR water suppression. The implants have distinct shapes, and no signs of rupture.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Usually, more attention is dispensed to the implant rupture. The classical findings of breast implant rupture are related to the intra or extracapsular failure. 

 

One well known finding is the linguine sign related to the intracapsular rupture. It is observed as multiple curvilinear low signal intensity lines surrounded by the high signal intensity silicone gel. These lines represent the collapsed implant shell floating within the silicone gel. It is considered the most reliable sign of rupture and also can be seen on ultrasound examinations. In spite of this, caution must be exercised in order to differentiate the linguine signal from complex radial folds that can mimic rupture and lead to misinterpretation. Fig. 10-13

 

Fig. 10: T2 FSE sagittal image. The implant is submuscular. The linguine sign is observed, compatible with intracapsular rupture. Droplets with signal intensity similar to the water are seen inside the implant, arrow.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 11: Same patient as Fig.10. STIR water suppression image. Observe the hypointense curvilineous lines and linguine sign, indicating intracapsular rupture. The water signal droplets were suppressed, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 12: Axial T2 FSE image. The left implant shows intracapsular rupture, linguine sign, arrow. The right implant does not show evidence of rupture.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 13: Same patient as Fig. 10. Axial STIR water sat image. Unilateral intracapsular rupture. Observe the nipple's high signal intensity, it is frequently observed, even with all the shimming attempts. Usually the nipples do not suppress their signal and can be seen, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Unlike rupture, gel bleed represents the silicone gel leakage through an intact implant shell. It is believed that most, perhaps all implants, will eventually have gel bleed. Although most of the gel bleed is not detected by MRI, depending on its amount it may be observed. If it is focal, the tear drop sign can be seen. Fig. 14


Fig. 14: The tear drop sign, arrow. It most likely represents gel bleeding.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

However, if extensive gel bleed occurs its appearance can mimic intracapsular rupture. Sometimes it is difficult, if not impossible, to make the differential diagnosis considering the MRI findings.

 

The presence of silicone outside the implant usually represents extracapsular rupture. Fig. 15,16

 

Fig. 15: T2 FSE and STIR water suppression sagittal image. Silicone outside the implant indicating extracapsular rupture, arrow.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Fig. 16

 

Fig. 16: Same patient as Fig. 15. Axial image, STIR water sat. Silicone outside the implant, extracapsular rupture, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

 

Another situation that requires careful attention is when the patient has been submitted to implant replacement, especially if previous rupture is mentioned or known. Residual silicone can simulate rupture, particularly in ultrasound exams, due to the detection of a snowstorm pattern. Fig. 17-20

 

Fig. 17: Sagittal imaging, T2 FSE. This patient was referred to Breast MRI due to the detection of snowstorm pattern during ultrassonographic exam that raised the suspicion of extracapsular rupture. In the MRI there was no evidence of rupture. There is a focal and discrete presence of material with signal intensity similar to the implant, anterior and posterior to it, arrows. This is better seen on STIR water sat image, next figure.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 18: Same patient as Fig. 17. STIR water suppression sagittal image. The implant is intact and there is silicone outside of it. The patient had been submitted twice to implant replacement due to rupture. The silicone outside the implant, arrows, is related to silicone residue from previous implants. This residue was the reason for the snowstorm pattern detected during the US exam.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Fig. 19: T2 FSE axial image. Same patient as Fig. 17. There are minimal peri implant fluid and radial folds.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 20: Same patient as Fig. 17. STIR water suppression image. The implant has high signal intensity, the presence of silicone outside the implant, arrow, is related to previous rupture.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Although initially thought to be inert, silicone has been shown, at least in some population, to induce fibrosis, which can invade muscle tissue. Silicone has also been reported to migrate to more distal areas of the body like the elbow, the subcutaneous tissues, including lower abdominal wall and inguinal canal, as well as between the pectoral muscles.6 Fig. 21-24


Fig. 21: T2 FSE sagittal image. The silicone implant shows linguine sign. The silicone migrated to the surrounding tissue, compare to next figure.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 22: Same patient as Fig. 21. Sagittal STIR water suppression image. Extensive migration of silicone to the glandular tissue peri implant can be seen, arrows. In the implant linguine sign is identified, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 23: Axial T2 FSE image. On the left side, the space between the major and minor pectoral muscle, arrows, is enlarged. Compare it to STIR water sat sequence, next figure.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 24: Same patient as Fig. 23. STIR water suppression axial image. Silicone has migrated and it is located between the pectoral major and minor muscles, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Occasionally, silicone may bleed through the semipermeable envelope membrane and in such cases it may be detected in lymph nodes. This can also happen when an envelope has ruptured. Fig. 25,26


Fig. 25: Sagittal T2 FSE image. This patient complained about axillary palpable mass, and informed that the implant manufacture is PIP™. The axillary lymph nodes are enlarged, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 26: Same patient as Fig. 25. Sagittal STIR water sat image. There is no evidence of implant rupture. Note a radial fold. The axillary lymph nodes form a cluster and there is silicone infiltration on them, explaining the palpable mass, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Recently, women in many countries became worried about their breast implants due to the scandal involving two manufacturers, PIP™ and Rofil™ Fig. 27-31. Industrial grade silicone unsuitable for medical use was utilized in such implants. PIP™ implants showed 2-3 times greater rupture rates than other implants.8 It may be  even higher, but only time will show what the consequences will be.9


Fig. 27: Axial images, T2 FSE and STIR water sat. Rofil™ implant. There was a finding interpreted as suspicious of focal herniation, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 28: Same patient as Fig. 27. Sagittal T2 FSE and reformatted imaging. There were no findings suggesting rupture of the Rofil™ implant.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 29: Same patient as Fig. 27. During surgery no herniation or rupture was found. Courtesy: Prof. Dr. José Yoshikazu Tariki. The implant was removed with its fibrous capsule intact, see next figure.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 30: Same patient as Fig. 27. The implants and its fibrous capsule. The surgeon exposed the thin fibrous capsule. Courtesy: Prof. Dr. José Yoshikazu Tariki.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 31: T2 FSE and STIR water sat sagittal. Rofil™ breast silicone implant. Exams in January, 2013 (left) showed extensive implant rupture, arrows, non-existent in the previous exams performed 11 months before (right). The patient referred no trauma.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

The PIP™’s rupture aspect can appear similar to that observed in other implants, but in the majority of cases we have seen more exuberant findings. Peri implant fluid seems to be more substantial. Fluid inside of the implant and following the gel that migrated seems to be more frequent than on the medically approved devices. The implant shell may collapse partially and form the linguine sign, but an exuberant pattern resembling an “explosion or fracture” can be seen instead, even in patients who deny trauma. In one patient, the plastic surgeon claimed that he found a lake surrounding and mixing with the silicone gel. Fig. 32-36


Fig. 32: Sagittal T2 FSE and STIR water sat images. PIP™ implant. The patient denied trauma, and referred breast assimetry. Implant failure is demonstrated in the MRI, there is a broken aspect of the implant, the silicone migrated to the axillary lymph nodes, white arrows. STIR water sat high signal intensity in the lymph nodes supports the suspicion of silicone infiltration. Fluid with water-like intensity is seen permeating the PIP™ implant. Peri implant fluid, yellow arrow.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 33: Sagittal T2 FSE and STIR water sat images. Same patient as Fig. 32. The implant is ruptured/fractured. There is fluid peri and inside of the implant. The axillary lymph nodes contain silicone, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 34: Axial T2 FSE and STIR water sat images. Same patient as Fig. 32. There is no evidence of rupture in the right PIP™ implant, in the left implant the findings are exuberant. The arrow indicates silicone in a lymph node of the thoracic internal chain.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 35: Axial T2 FSE and STIR water sat images. Level I axillary lymph nodes, lateral to the pectoral minor muscle, presents with silicone infitration, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 36: The PIP™ implant was fragmented and there was a large amount of fluid surrounding it. Courtesy: Dr. André Luiz de Miranda Barbosa MD.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

Moreover, migration of this non-medical silicone gel to the lymph nodes has been noticed and reported, not only to the axillary ones, but also to the internal thoracic chain. Fig. 37-39. There is one report of silicone migration to the pericardic lymph nodes.9 

 

Fig. 37: Sagittal T2 FSE image at the intercostal level, medial. The enlarged lymph node is detected, arrow. The Figs. 37-39 refer to the same patient, multiple findings. Sagittal STIR water suppression, same location. The enlarged thoracic internal chain lymph node has silicone infiltration, arrow.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 38: Sagittal T2 FSE imaging at the intercostal level, medial. Another two enlarged lymph nodes are detected, arrows. Sagittal STIR water suppression image. The enlarged lymph nodes have silicone infiltration, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 39: T2 FSE axial image. In the left breast silicone implant intracapsular rupture is seen, linguine sign. In the right side no evidence of implant failure was detected. The enlarged thoracic internal lymph node is demonstrated, arrow. STIR water suppression axial image. In the left implant the linguine sign is seen. The high signal intensity observed in the enlarged thoracic internal lymph node strengthens the impression that silicone migration and infiltration of this lymph node occurred, arrow.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

An anecdotal case, and the questions it can raise:


It was mentioned before that intravenous contrast is not necessary to depict silicone breast implants alterations. However, there may be exceptions. In one patient, enlarged lymph nodes were noticed during the exam, but without evidence of implant rupture.

The radiologist decided to use intravenous contrast in order to study the glandular tissue, looking for the cause of this finding. It was concluded that the lymph nodes' enlargement was due to silicone infiltration. It was intriguing to observe the pharmacokinetic behavior of these lymph nodes, which was quite different. The contrast agent was delayed in its completion of the usual wash in and wash out time.

Also, the enhancement amplitude was lower than expected, and just the periphery of such lymph nodes showed partial and weak enhancement. We confirmed that the intravenous contrast injection was adequate by comparing it to the heart’s enhancement wash in and wash out pattern. This observation made us wonder if this non-medical silicone infiltration could interfere in the lymph nodes' function and have clinical relevance, or cause any future discomfort or other consequences.

It is not in our knowledge that any other report about this pharmacokinetic behavior in lymph nodes with silicone infiltration has been written. Would a modification in the treatment of these patients be necessary? Since we believe and have learned for so many years that MRI exams for breast implants do not require contrast injection, we do not have data to compare our findings to. In our patients' selection, the use of intravenous contrast was rare. Fig. 40, 41


Fig. 40: T2 FSE and T1 FSPGR fat sat post contrast sagittal images. The axillary lymph nodes are enlarged, and the enhancement is predominant in their periphery.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 41: FSPGR T1 fat sat sagittal imaging, 1 pre and 3 post intravenous contrast injection. It is expected to observe an intense and rapid wash in and wash out pattern in the lymph nodes. But, due to silicone infiltration, there occurred low amplitude enhancement, especially in the periphery of the lymph nodes, white arrows. Some lymph nodes show discrete enhancement, yellow arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 


A surprising finding:


This patient was referred to a plastic surgeon after ultrassonographic diagnosis of intracapsular rupture of her implants. It was believed by the surgeon that the implants were placed anterior to the major pectoral muscle. During the operation the surgeon did not find the implants. Despite this, he decided to include new ones in the subglandular region, anterior to the pectoral muscle. An MRI exam was requested, which revealed the old implants posterior to the muscle, with linguine signs and partially collapsed, and the new ones in the retroglandular space. Fig. 42-44

 

Fig. 42: T2 FSE and the correspondent STIR water sat sagittal images. The implants included in the recent surgery are located anterior to the major pectoral muscle. A discoid structure related to the reinforcement patch is seen, yellow arrows. The old implants are partially collapsed, linguine sign is observed, white arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 43: Same patient as Fig 42. T2 FSE axial images. The new implants are placed anterior to the major pectoral muscle. The old ruptured implants are posterior to the muscle, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 44: Same patient as Fig 42. STIR water sat axial images. The old ruptured implants showing the linguine sign, arrows.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

An unusual situation:


Migration of silicone gel to the lactiferous duct is unusual, but it was observed in one patient. Fig. 45-48

 

Fig. 45: Mammography: medio lateral oblique and cranio caudal images. There is evidence of silicone migration superior to the implant, arrows. At this time it was decided that removal or replacement of the implants was not necessary. Fig. 45-48 show the same patient, distinct imaging modalities.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 46: Mammography, MLO spot compression view. Two years later than the previous exam. At this time the patient presented with left nipple discharge, and extensive infiltration of high density material is noted, part of it forming linear branching distribution.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 47: Mammography, bilateral MLO view with implant displacement, Eklund. High density material with linear branching distribution is noted. There was a suspicion that the nipple discharge was due to silicone extravasation, an MRI exam was indicated to support the diagnosis.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR
Fig. 48: STIR water sat sagittal image. Note the linear branching distribution of the silicone, extending from the implant to the nipple, supporting the clinical and mammographic suspicion of migration of silicone gel to the lactiferous ducts.
References: MRI, Instituto de Ensino e Pesquisa DASA, Instituto de Ensino e Pesquisa DASA - Sao Paulo/BR

 

In this situation, a patient and her physician were aware that the imaging findings had shown signs of implant rupture. However, they concluded that there was no hurry to replace or remove the implant. But, after two years, the patient presented nipple discharge and there was a suspicion that it was due to extravasation of silicone gel. Mammography and MRI proved that silicone migrated to the lactiferous ducts and was responsible for the clinical complaint. 

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